Nursing progress notes cheat sheet

These are some notes my peers and I tend to write on some brief examples to give you some examples:

ABT therapy: Pt. on ABT tolerating therapy [insert name/dosage/route] with no adverse reactions noted. [temperature and other vitals that you may think is pertinent].

Lung sounds auscultated with findings, skin temperature ( is the patient flushed?) findings.

If on IV: additionally, IV line patent, no s/s of phlebitis and infiltration.

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Other notes:

( refusal of care)

Pt. found to self remove [apparatus] ( such as sling or abductor pillow, very major points of care). Education on [apparatus] ( specifically what you may have explained). Patient states understanding, " jfhsdkfhsjkf" but continues to non-adhere to precautions. Reapproached and stressed importance, patient continues to refuse. [ Other interventions you may have to do to maintain patient safety.] MD called/made aware. Will continue to monitor ( any vitals or pulses that may be pertinent).

Documenting IV and refusal of care has saved my butt many times ( not a lot of phonecalls!) and I hope this helped.

Not only are the above good advice but if they’re on a rehab for PT/OT you can also chart how they transfer and self care. ‘Pt transfers to bathroom with one person assist to stand pivot to wheelchair to toilet and back to bed. Pt needs lifting assist to stand. Is steady on feet. Mod I with all cares and hygiene.’

This has helped show the progress of patients in rehab and how they get better.

I am a bit curious. What type of system are you using in your facility for documentation etc?

Is there anyone in here that can give me a sample SOAP note for outpatient mental health to include things you do with the patient as far as skills